Inspection Reports for Somerset Health and Rehabilitation

The inspection was conducted to evaluate compliance with food service regulations, specifically to ensure that food and drink are served palatable, attractive, and at safe and appetizing temperatures.

The facility failed to serve food at proper temperatures as required by policy and state regulations. Observations and interviews revealed that hot foods were often served cold, with measured temperatures below the required thresholds for hot and cold food holding.

The inspection was conducted to assess compliance with regulatory requirements related to resident care, privacy, medication administration, infection control, and other nursing home standards.

The facility was found deficient in multiple areas including failure to ensure call bells were within reach, maintain confidentiality of medical records, timely notification of hospital transfers, completion and accuracy of Minimum Data Set assessments, development and revision of care plans, medication administration, bowel protocols, pressure ulcer care, food temperature and palatability, dialysis care, medication labeling and storage, and infection prevention and control practices. The Quality Assurance Performance Improvement committee failed to effectively address recurring deficiencies.

The inspection was conducted to review the facility's compliance with policies and procedures related to preventing abuse, neglect, and theft, specifically focusing on verification of nurse aide registry, nursing licenses, and criminal background checks for newly hired nursing staff.

The facility failed to complete Nurse Aide Registry verification for two newly hired nurse aides, failed to verify nursing licenses for three newly hired nurses, and failed to complete criminal background checks for four of five newly hired nursing staff reviewed. These deficiencies were confirmed by personnel file reviews and staff interviews.

The inspection was conducted to assess compliance with regulatory requirements related to resident confidentiality, medication storage security, food preferences accommodation, and provision of snacks according to resident needs and preferences.

The facility was found deficient in maintaining confidentiality of resident health information during medication administration, securing medication carts properly, honoring food preferences for residents, and providing nightly snacks as requested by residents. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.

The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, treatment and care, clinical record keeping, infection prevention and control, and other nursing services at Somerset Healthcare & Rehabilitation Center.

The facility failed to complete accurate Minimum Data Set assessments for two residents, did not monitor intake and output or follow bowel protocols for certain residents, lacked signed and dated diagnostic reports in clinical records, and failed to implement infection prevention and control measures including Enhanced Barrier Precautions for residents with indwelling devices or chronic wounds.

The inspection was conducted due to a complaint investigation regarding the facility's failure to revise residents' care plans with individualized interventions, ensure appropriate pressure ulcer care, and use safe transfer techniques during an emergency evacuation.

The facility failed to revise care plans for Resident 1, resulting in improper transfer techniques during a fire evacuation that caused a left hip fracture. Additionally, the facility failed to monitor pressure ulcers appropriately for Resident 2, lacking weekly wound measurements and assessments. Staff interviews and clinical records confirmed these deficiencies.

The complaint investigation substantiated that the facility failed to revise care plans appropriately, monitor pressure ulcers, and use safe transfer techniques during a fire evacuation, leading to Resident 1's left hip fracture.

The inspection was conducted to assess compliance with care planning and treatment orders for residents, specifically focusing on Resident 2's care plan and follow-up appointments related to Raynaud's syndrome with gangrene.

The facility failed to develop a comprehensive, individualized care plan for Resident 2 addressing her Raynaud's syndrome with gangrene and failed to follow hospital recommendations and physician orders for follow-up appointments. There was no documented evidence that Resident 2 attended or refused scheduled follow-up appointments with specialists.

The inspection was conducted due to a complaint investigation regarding a resident (Resident 2) who ingested hand sanitizer, resulting in a blood alcohol level of 0.29.

The facility failed to provide an environment free from accident hazards for Resident 2, who had a history of drinking hand sanitizer. Multiple empty bags and cups of hand sanitizer were found in the resident's room despite care plans and interventions to prevent access. The resident exhibited intoxication symptoms, and one-on-one supervision was implemented. The facility conducted searches and interventions after discovering the sanitizer but initially only performed visual room searches.

The investigation was complaint-related, involving Resident 2's ingestion of hand sanitizer. The resident had a history of alcohol intoxication and frequent ingestion of hand sanitizer. The complaint was substantiated by clinical records, staff interviews, and investigation findings.

The inspection was conducted to assess compliance with state and federal regulations regarding nursing home operations, including resident care, medication administration, infection control, and staff training.

The facility was found deficient in multiple areas including failure to implement abuse prevention policies, inaccurate resident assessments, incomplete care plan updates, failure to follow physician orders, medication accountability issues, inadequate infection control practices, and insufficient staff training.

The inspection was conducted to review the facility's compliance with care plan development and revision requirements, specifically to assess whether care plans were properly reviewed and updated for residents.

The facility failed to review and revise the care plan for one of three residents reviewed (Resident 2), as the care plan did not reflect the use of assistive devices such as round, blue foam build-ups on utensils and two-handled sippy cups. Interviews confirmed the omission was recently corrected.

The inspection was conducted to assess compliance with regulatory requirements related to treatment administration, medical record documentation, infection control, and adherence to physician and CRNP orders for residents at Somerset Healthcare & Rehabilitation Center.

The facility failed to ensure intravenous fluids were administered as ordered for Resident 10 and that CRNP orders were followed for Resident 11, including timely testing and treatment. Additionally, the facility did not ensure that the CRNP wrote, signed, and dated progress notes with each visit, and failed to implement proper infection prevention and control measures, including timely COVID-19 testing for symptomatic Resident 11.

The inspection was conducted to investigate allegations of verbal abuse and failure to report suspected abuse involving Resident 2, as well as to review the facility's compliance with reporting and documentation requirements.

The facility failed to report an allegation of verbal abuse involving Resident 2 and did not conduct a thorough investigation into the incident. Additionally, the facility failed to ensure accurate and complete clinical documentation for Resident 5's wound care treatment.

The complaint investigation focused on an allegation that the Director of Nursing verbally abused Resident 2 by yelling at her after she pulled a fire alarm. The facility failed to investigate or report this incident to the Department of Health and the Area Agency on Aging.

The inspection was conducted as a routine regulatory survey to assess compliance with nursing home regulations, including resident care, medication management, infection control, and staff performance.

The facility was found deficient in multiple areas including failure to notify residents or representatives about bed-hold policies, inaccurate Minimum Data Set assessments, incomplete care plan updates, failure to follow physician medication orders, inadequate pressure ulcer care, improper respiratory monitoring, missing progress notes by nurse practitioners, incomplete nurse aide performance evaluations, lack of accountability for controlled medications, failure to ensure residents were free from unnecessary medications, significant medication errors, ineffective quality assurance performance improvement, failure to implement infection control policies properly, and failure to ensure influenza vaccinations were administered as required.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication administration, respiratory care, and physician's orders for residents.

The facility failed to ensure that physician's orders for medications and treatments were followed for three residents. Specifically, Resident 25 was not provided prescribed tubigrip compression stockings; Resident 77 did not receive prescribed thyroid medication on several dates; and Resident 17's oxygen saturation was not monitored as ordered.